Provider Demographics
NPI:1578582979
Name:LOPEZ, BERTHA A (MD)
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:A
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ERIE CT
Mailing Address - Street 2:6040
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2566
Mailing Address - Country:US
Mailing Address - Phone:708-386-1390
Mailing Address - Fax:
Practice Address - Street 1:1 ERIE CT
Practice Address - Street 2:6040
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2566
Practice Address - Country:US
Practice Address - Phone:708-386-1390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090643207VM0101X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207667OtherMEDICAER GROUP NUMBER
IL36090643Medicaid
IL1621924OtherBCBS GROUP NUMBER
ILK02266Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
IL36090643Medicaid